From the Guidelines
Pancreatic insufficiency should be diagnosed through a combination of clinical assessment and laboratory tests, with the most reliable diagnostic test being fecal elastase measurement, as recommended by the AGA clinical practice update 1. The diagnosis of pancreatic insufficiency involves a comprehensive approach, including:
- Clinical assessment of symptoms such as steatorrhea, weight loss, abdominal pain, and malnutrition
- Laboratory tests, including:
- Fecal elastase test, which is the most appropriate initial test and should be performed on a semi-solid or solid stool specimen, with levels <100 mg/g indicating pancreatic insufficiency and levels of 100–200 mg/g being indeterminate for pancreatic insufficiency 1
- Other tests, such as 72-hour fecal fat collection and serum trypsinogen, may also be useful in certain cases
- Imaging studies, such as CT scans, MRI, or endoscopic ultrasound, can identify structural pancreatic abnormalities that may cause insufficiency, but are not diagnostic of pancreatic insufficiency itself 1 The AGA clinical practice update recommends that pancreatic insufficiency be suspected in patients with high-risk clinical conditions, such as chronic pancreatitis, relapsing acute pancreatitis, pancreatic ductal adenocarcinoma, cystic fibrosis, and previous pancreatic surgery 1. The fecal elastase test is the preferred diagnostic test because it is non-invasive and not affected by pancreatic enzyme replacement therapy 1. Once diagnosed, patients should be evaluated for nutritional deficiencies, particularly fat-soluble vitamins (A, D, E, K), vitamin B12, and essential fatty acids, as these are commonly depleted in pancreatic insufficiency 1. Treatment with pancreatic enzyme replacement therapy (PERT) is required to improve outcomes and reduce the risk of complications related to fat malabsorption and malnutrition 1.
From the Research
Diagnosis of Pancreatic Insufficiency
- The diagnosis of pancreatic insufficiency can be made using various tests, including fecal elastase-1 level testing 2 and 72-h stool for fecal fat estimation 2.
- Fecal elastase-1 level testing is a sensitive test, but it does not have a good agreement with 72-h stool for fecal fat estimation 2.
- The 72-h stool for fecal fat estimation is considered a gold standard indirect test for the diagnosis of pancreatic exocrine insufficiency, but it is cumbersome for both patients and laboratory personnel alike 2.
Role of Pancreatic Enzyme Replacement Therapy
- Pancreatic enzyme replacement therapy (PERT) is safe and effective at treating pancreatic exocrine insufficiency 3, 4, 5.
- PERT reduces fecal energy and fat loss in patients with chronic pancreatitis and pancreatic exocrine insufficiency 6.
- The benefits of PERT in chronic pancreatitis include improved coefficient of fat absorption, reduced faecal fat excretion, and improved quality of life 4.
Testing and Monitoring
- Testing fecal elastase-1 level is useful for the diagnosis of pancreatic exocrine insufficiency 3.
- Monitoring of therapy can be done by assessing the coefficient of fat absorption, faecal fat excretion, and abdominal pain 4.
- Current research is aimed at developing better means to monitor therapy and improving the efficiency of action of pancreatic enzyme replacement therapy in the duodenum 5.